Professional Documents
Culture Documents
TABLE OF CONTENTS
Introduction
1
About this Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
About the National Child Traumatic Stress Network . . . . . . . . . . . . . .2
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Who Should Be Trained?
II
54
III
INTRODUCTION
ABOUT THIS GUIDE
Children who have experienced the traumatic death of a person significant in their
lives may have reactions and symptoms that we are beginning to understand are
distinct from the grief following nontraumatic death. We believe that children who
have experienced traumatic grief and who are troubled by overwhelming traumatic
memories can be identified and helped to cope with traumatic reactions and
ultimately remember the person who died in a healthy, meaningful way.
The material presented in The Courage to Remember video and this companion guide
represents the results of significant advances in the field of childhood traumatic grief
and the unique collaboration of researchers and clinicians in academic and community
settings throughout the country. We developed the video and guide using extensive
expert involvement and commentary. Although the focus of these training materials
is on individual work with school-age children and teens, additional information and
resources are provided regarding work with young children and groups. The materials
provide specific guidelines and options for interventions to
educate care providers about childhood traumatic grief,
introduce others to principles of treatment that have been identified as helpful
in treating the condition, and
offer practitioners an opportunity to enhance their treatment skills.
We hope to improve awareness about childhood traumatic grief as well as increase
the ability of clinicians to respond in the most effective way possible.
ACKNOWLEDGMENTS
We wish to thank the professionals who appeared in Its OK to Remember and
The Courage to Remember: Dr. Judith Cohen, Dr. Robin F. Goodman, Dr. Tamra
Greenberg, Dr. Alicia Lieberman, Dr. Anthony Mannarino, Dr. Robert Pynoos, and
Karen Stubenbort, as well as many other professionals from the National Child
Traumatic Stress Network.
In addition we gratefully acknowledge the individuals and organizations that
contributed to the review of these materials, including: SD Williams, Stephanie
Handel, Dana Naughton, Dr. Ann Kelley, Dr. Esther Deblinger, Bereavement Center
of Westchester, Center for Trauma Recovery University of MissouriSt Louis, Healing
the Hurt, Highmark Caring Place, Safe Horizon, Wendt Center for Loss and Healing,
Center for Child and Family Health of North Carolina, National Center for Child
Traumatic Stress faculty and staff, and the SAMHSA/CMHS National Child Traumatic
Stress Initiative program staff.
We also would like to recognize the many hours of creative and editorial time spent
by our production team, Dr. Robin Goodman, Dr. Bob Franks, and Mike Wertz from
Apple Box Studios, in the development, revision, and final production of these
educational materials.
This work would not be possible without the support and vision of Dr. Robert Pynoos
and Dr. John Fairbank, co-directors of the National Center for Child Traumatic Stress
at UCLA David Geffen School of Medicine and the Duke University School of Medicine.
And special thanks go to the families who courageously shared their stories.
The video and guide cover issues related to the diagnosis and treatment of childhood
traumatic grief in the same sequence. This guide provides more in-depth
explanations, step-by-step instructions, additional resources, and quoted excerpts
from professionals and family members seen in the videos to identify main concepts.
A variety of different icons have been used throughout the guide to help you more
easily find the information you need. Icons will be used to highlight the following:
GLOSSARY OF ICONS
Important issues or terms
are defined.
DEFINITION
MAIN
CONCEPT
T R E AT M E N T
COMPONENT
CASE
EXAMPLE
CHILD
PA R E N T
CHILD
PA R E N T
JOINT
Different treatment
components and suggested
tools to use with clients
will be described.
REFERENCE
RESOURCE
CASE
EXAMPLE
CASE
EXAMPLE
After being broadsided, the car was spinning out of control. When it stopped, eightyear-old Devon, who was buckled up in the back seat and pinned in the car, yelled for
his mother to wake up. He heard the sirens, then watched the paramedics drag his
mother onto the street and saw blood running down her face. Later, whenever he rode
in a car, he refused to put on his seat belt because he wanted to get out as fast as
possible in case of an accident.
Twelve-year-old Annas brother drowned in the neighbors pool. She had a fight with him
right before he left, teasing the five-year-old about not being able to swim. Later she
frequently had nightmares in which she couldnt breathe, so she stayed up most of
the night. In school, she was exhausted, sleepy, and couldnt concentrate. Her grades
plummeted, but she said she didnt care and deserved whatever punishment she got.
Childhood traumatic grief is a condition in which children who lose
loved ones under very unexpected, frightening, terrifying, traumatic
circumstances develop symptoms of posttraumatic stress and
other trauma symptoms that interfere with their ability to progress
through typical grief tasks, because they are stuck on the traumatic
aspects of the death. Judith Cohen
DEFINITION
Childhood traumatic grief can develop following the death of a significant person
when the death has been perceived by the child as traumatic. The hallmarks of the
condition are reactions related to (1) trauma, a situation that is sudden and terrifying
and that results in death and may have also been life threatening for the child, and
(2) grief, feelings of intense sadness and distress from missing the person who died
and the changes that have resulted. The distinguishing feature of childhood traumatic
grief is that trauma symptoms interfere with the childs ability to navigate the typical
bereavement process. In other words, a childs preoccupation and inability to relinquish
a focus on death leaves little or no room for other more helpful thoughts about
the person who died, leaves little emotional energy for adjusting to change, and
compromises the childs ability to function in school or with friends. According to our
current understanding, childhood traumatic grief is distinct from uncomplicated
bereavement and conditions such as PTSD, yet it shares features of both. The
definition, characteristics, and assessment of childhood traumatic grief are still
evolving and likely vary due to such things as the type of death, age and cognitive
ability of the child, culture and beliefs, and family situation.
MAIN
CONCEPT
The childs perception, not just the cause of death, plays a key role in determining the
development of symptoms. Not every child develops traumatic grief after a death that
happened in a particularly dramatic or threatening manner, such as death from a homicide,
war, or motor vehicle accident. In some cases, childhood traumatic grief can result
from a death that most would consider expected or normal, such as death from illness
or natural causes. There may be isolated traumatic moments that can be lodged in
the childs memory, such as seeing a parent in profuse pain, that provoke the childs
reaction. Childhood traumatic grief can affect childrens development, relationships,
achievement, and later effectiveness in life if not treated or otherwise resolved.
Children loose their developmental momentum that they had been
pursuing. They need support to regain that developmental momentum,
and without the support it often happens that children really stop
gaining these skills that are appropriate for their age, and that has
long-term repercussions. Alicia Lieberman
The traumatic aspects of the death and the childs relationship to the person that
died are entwined in such a way that thoughts or reminders of the trauma and
overwhelming painful grief about the person who died are linked together. The childs
traumatic reaction can stem from the sudden and horrific nature of the death with
or without the childs life also being in danger. The grief reaction stems from the
sadness of missing the person and all that has changed. The child contends with
the complex mix of trauma and grief. Hence, in providing treatment the clinician must
address both.
CASE
EXAMPLE
A child survivor of a car crash in which her mother was killed may be confronted with
reminders of the smell of rubber and gasoline, the fear of being trapped in the car,
the sight of blood and a mothers lifeless body, and a caretaker whose absence is felt
every waking moment.
children in different countries may also have more or less exposure to death throughout
their life, which can influence their response. Regarding inter vention, you must be
sensitive to instances when certain treatment principles may be contrary to what is
accepted practice in the childs particular family. For those times when a practitioner is
unfamiliar with a familys practices and beliefs it is essential to seek consultation or
consider additional referral.
CASE
EXAMPLE
A six-year-old bereaved survivor of a motor vehicle crash repeatedly drew and cut
out replicas of the car and steering wheel. He built an oversized speedometer so
the driver of the other car would notice he was driving too fast. The boy went on
to make a car with extra protection that was strong enough to withstand any crash.
DEFINITION
Traumatic events can involve an actual death, other loss, serious injury, or threat to
the childs own life or well-being. These events could include natural or man-made
disasters, violence, war, or accidents. A child may be traumatized by direct exposure,
witnessing the event, or hearing about another persons experience. For some children,
the response can have a profound effect on how they view themselves and the world.
They may develop changes in their behavior (externalizing problems) or emotional
functioning (internalizing problems). Left untreated, the severe trauma-related reactions
can lead to more serious and chronic difficulties and, in some cases, coalesce into
PTSD. PTSD is diagnosed when the child has specific symptoms that continue for a
month or more following exposure to a traumatic event. The symptoms fall into the
three categories of re-experiencing, hyperarousal, and avoidance.
10
When children with childhood traumatic grief show reactions and symptoms characteristic
of PTSD, the reactions and symptoms are directly related to the death and interfere with
the childs day-to-day functioning and bereavement work. Children may present with other
symptoms not necessarily associated with PTSD but related to bereavement and traumatic
death. These may include guilt, yearning, anger, and rescue and revenge fantasies.
CASE
EXAMPLE
Lisas Drawings
It was hard for Lisa to talk about her mother, who she dearly loved, without feeling as
if she was back in that room. In the days and weeks after the murder, when she had
that feeling, she would focus on her mother being killed. But as she stood at the door,
frozen in place, one suspects she worried about herself as well as about her mother
being killed.
DEFINITION
CASE
EXAMPLE
In childhood traumatic grief, the interaction of traumatic and grief symptoms is such
that any thoughts or reminders, even happy ones, about the person who died can lead
to frightening thoughts, images, or memories of how the person died.
Kevin, the 17-year-old brother of 15-year-old Briana, was killed in an avalanche. His body
was never found. She was haunted by feelings of guilt for not demanding he stay at the
lodge. She was so distraught that she isolated herself from friends. On further questioning,
it became clear that Briana and Kevin had many of the same friends. So when Briana
was with them, she was reminded of the good times they used to have together. But
this quickly led to her thinking about Kevin suffocating and it being her fault.
11
Any death can be difficult for a child, and certain reactions are more likely than others.
Uncomplicated bereavement is the intense sadness and longing for the deceased
that children typically feel after the loss of a loved one. Complicated bereavement
has been described in adults as bereavement complicated by separation distress
and traumatic symptoms related to the loss of the security-enhancing relationship
with the deceased. This has not been clearly defined as a condition for children.
12
13
MAIN
CONCEPT
Throughout their lives, children continue to adjust to the loss and develop new ways
of coping. Over time, it is helpful for children to relate to their loss by engaging in,
and mastering, certain bereavement tasks. The following chart presents the outcome
of common bereavement tasks and how childhood traumatic grief interferes with
completion of these tasks.
14
MAIN
CONCEPT
15
MAIN
CONCEPT
Children can develop childhood traumatic grief when they experience the death of a
significant person, such as a parent, a sibling, or a close friend. Children of all ages,
even a young preschooler, can have a traumatic reaction to a death, especially of a
primary caregiver. It is estimated that five percent of all children in the United States
experience the death of a parent before the age of 15, and children under the age of
three are often present when a sibling or parent dies in a traumatic circumstance,
making young children particularly vulnerable and in need of attention.
However, not all children who have experienced a death develop childhood traumatic
grief. In fact, many recover and do well over time. Although it is true that the majority
of children who experience a death do not develop childhood traumatic grief, the
number of children who do struggle with childhood traumatic grief is quite significant.
For example, up to 70 percent of children in inner city communities have seen
someone shot or stabbed. Even if only five percent of these children develop childhood
traumatic grief, this translates into thousands of children developing this condition
each year. Although all children witnessing a homicide are likely affected in some way,
some are better able to tolerate the experience, whereas others are deeply impacted
and cannot continue on as well as before the death.
MAIN
CONCEPT
Childrens symptoms and presentation may vary according to factors related to their
age, stage of development, culture, religious beliefs, social supports, and family
functioning. However, the most common signs of childhood traumatic grief that
can occur across the different developmental stages include intrusive memories
(e.g., nightmares) and increased arousal (e.g., irritability or difficulty sleeping), both
of which can lead to avoidance and numbing to manage the distress. Not all children
will meet criteria for a diagnosis of PTSD. A child may have other difficulties more
typically seen following an uncomplicated death, such as depression or anxiety.
Children may exhibit problems at home, in school,
or with friends that are not readily understood
as related to the death or usual trauma-related
symptoms. For example, avoidance may be
recognized by its consequences, such as poor
concentration and failing grades, resistance to
engaging in previously enjoyed activities, or refusal
to participate in events or activities related to
remembering the person who died. The point in a
childs life at which the death occurred is a factor
in adjustment. Childrens reactions to trauma and
death can have a varied impact on their later
16
CASE
EXAMPLE
When Jamal was seven, he was with his 39-year-old father, who died suddenly of a
heart attack. At 16, Jamal had an anxiety attack when he had chest pain from
bronchitis. He thought he was going to die.
17
Although it is not always possible to predict who will develop childhood traumatic
grief, there are a number of factors that put children at greater risk for developing
problems following a traumatic death. You should be alert to children who have
experienced the following:
Previous traumas: Children who have experienced a previous trauma
(e.g., abuse or a natural disaster) can be more vulnerable to experiencing a
more intense reaction to a new trauma or traumatic loss. The circumstances
of the current death may cause the person to remember and react to a
previous trauma, and dealing with both can make the current reactions more
intense or severe.
Prior mental health problems: Children with a history of mental health problems
may be vulnerable to having those difficulties exacerbated by the traumatic
death and the accompanying stress reactions. The prior mental health problems
can also make it more difficult for a child to manage the current situation.
Bereaved children are also at risk for depression and anxiety, hence it is
important to thoroughly assess and differentiate a childs response.
Impaired functioning of parents and family: The ability of childrens primary
caregivers to manage their own reactions to a traumatic death has a direct
effect on how a child is able to cope with his or her own reactions. In a culture
where memorialization is encouraged, a caregivers avoidance of talking about
the person who died can make the child reluctant to communicate about the
death and hence interfere with the childs adjustment.
Poor/lack of social support: If a child is feeling unsafe, abandoned, sad, and
angry following a traumatic death, a good social support network can provide
comfort and reassurance. It is more difficult to seek and engage in new
supportive relationships than to find support in relationships already in place.
Secondary adversities: The death of a significant person often results in many
life changes. The changes that result from the death, such as remarriage,
loss of health or employment benefits, and changes in financial circumstances,
housing, or school can cause tremendous stress for the child and family. Other
related activities, such as custody and criminal proceedings, also contribute to
the childs stress reactions.
CASE
EXAMPLE
Jonathon lived with his single-parent mother. He did not get along well with his father
and rarely saw him. After his mother died in a homicide, his father obtained custody
and the boy moved to a new city. On top of witnessing his mothers death, he now
had to deal with a new school, loss of his friends and church support, and the
adjustment to living with a father he barely knew, a stepmother, and stepsiblings.
The Courage to Remember: Childhood Traumatic Grief Curriculum Guide
National Child Traumatic Stress Network
NCTSN.org
18
MAIN
CONCEPT
The treatment described in detail here is for use with individual school-aged children.
Initially the focus of treatment is on the traumatic nature of the death. The child first
learns ways to cope with the frightening thoughts, images, feelings, and arousal
associated with the traumatic experience. It is crucial to carry out the components of
childhood traumatic grief treatment in a progressive fashion in order to help the child
learn and build skills enhancing self-efficacy. Once the traumatic aspects recede, the
practitioner is better able to help the child integrate what was learned with a less
trauma-focused world view and help the child actively engage in remembering the
person who died. The child is then also better able look at the current and enduring
aspects of bereavement.
19
CASE
EXAMPLE
MAIN
CONCEPT
Fifteen-year-old Thomas was home watching television when his father jumped to his
death outside their apartment window. The family was unaware that he had stopped
taking his medication for his schizophrenia. Thomas was afraid to go to sleep at night
due to the recurring images he saw of his father on the ground. During the day, he
was feeling the urge to jump out the window himself. He learned ways to manage the
impulses, talk about the suicide, and stop blaming himself for not making his father
take his medication and saving him. When baseball tryouts came and went, he drew
pictures about feeling lonely if he played without his father watching. Gradually he
was able to think of how he could still feel encouraged by his father and enjoy going
to games with the rest of his family.
Researchers and practitioners in the fields of trauma and bereavement have
collaborated, piloting their work and sharing their experiences to develop the current
childhood traumatic grief interventions. The childhood traumatic grief intervention
components being described are based on the common practice of supportive
bereavement counseling utilizing both directed activities and nondirected play
interventions and cognitive behavioral therapy (CBT)oriented treatment that has been
traditionally used to address problems related to
trauma as well as anxiety and depression. Cognitive
behavioral techniques have been adapted to teach
skills to manage specific thoughts and behavioral
distress reactions the child is having in situations
that generate unhelpful and unpleasant feelings.
Gradual exposure through creation of a story is based
on the CBT technique that encourages the child to
speak directly about the traumatic circumstances
related to the death what was heard, seen, and
most troubling and to develop helpful strategies,
rather than avoidance, for dealing with traumatic
memories. Once the childs trauma-related reactions
recede, the child can engage in activities enabling
access to comforting memories and adjust to a life
that is now different. Thus, following the sharing of
the childs experience, treatment focuses on reconnecting the child to significant
memories about the person who died, their relationship, and plans for the future.
INDIVIDUALIZED TREATMENT
MAIN
CONCEPT
Children and parents come to treatment with their own strengths, experiences, and
expectations. Bereaved individuals may be in pain but should be supported to find
and use the internal and external resources that have been most helpful at other
times in their life. All treatment should be based on a strong, caring relationship,
guided by the principle of collaboration between client and practitioner in a way that
communicates a belief in the individuals own abilities.
20
MAIN
CONCEPT
The treatment being described should not be followed in a cookbook fashion. You
should be flexible and creative in adapting the techniques to fit a particular client in a
particular treatment setting. Different strategies can be modified according to a childs
and familys culture, beliefs, customs, preferences, and styles. There are a number of
variations that can be used in teaching the various skills, and you should adapt them
to the childs age and preference. For example, play rather than direct discussion may
be more appropriate when working with young children, and anticipation of future
mourning rituals should be integrated into the work. Clinical judgment and expertise
should determine the overall format, structure, and pace of treatment for specific
childhood traumatic grief issues and any other mental health problems.
Although the training video focuses on treating children and their parents in an individual
format, very similar treatment interventions have been utilized when working with
groups and with older adolescents. For example, trauma- and grief-focused groups
were used to help Bosnian youth recover from childhood traumatic grief following the
war in their country. This group treatment was also piloted for children who developed
childhood traumatic grief in response to urban violence in Los Angeles. Following the
description of the components and activities used with individual school-age children,
you will find guidelines for adapting the treatment for use with groups. Additionally,
treatment guidelines have been developed for preschoolers whose parents have died;
these focus on issues of attachment and safety. Introductory guidance when working
with young children and groups is provided later in the curriculum.
For further information and treatment manuals for work with toddlers, adolescents,
and groups you are directed to the following resources:
RESOURCE
Lieberman, A. F., Compton, N. C., Van Horn, P. & Ghosh Ippen, C. (2003) Losing
a parent to death in the early years: Guidelines for the treatment of traumatic
bereavement in infancy and early childhood. Washington, DC: Zero to Three Press.
Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement in
children: Treatment manual, available by contacting the National Resource Center
for Child Traumatic Stress at (919) 682-1552 or nationalresourcecenter@duke.edu.
Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement in children:
Group treatment manual, available by contacting the National Resource Center
for Child Traumatic Stress at (919) 682-1552 or nationalresourcecenter@duke.edu.
Saltzman, W. R., Layne, C. M., Pynoos, R. S. (2003) Trauma/grief-focused
intervention for adolescents, available by contacting wsaltzman@sbcglobal.net.
21
CASE
EXAMPLE
MAIN
CONCEPT
At bedtime, three months after his father died, seven-year-old Ben asked his mother
to read a book. It was one of his favorites that his father always used to read to him.
Ben joined in, laughed, and imitated the different characters as his father had done
many times. Although a pleasant reminder for Ben, Mom struggled to finish and
quietly cried for hours once alone in her own bed.
It is crucial to include parents in the childhood traumatic grief treatment. When
working with young children, treatment with the parent focuses on enhancing the
parent-child attachment in addition to supporting and encouraging positive parenting
and the parents processing of her own traumatic grief reactions. With children
school-age and older, the objective in working with parents is to
understand the specific family and cultural beliefs,
inform them about expected adult and child reactions and course of bereavement,
help them process their own trauma and grief reactions,
maintain good parenting practices while bereaved,
learn ways to help the child with his or her trauma and grief reactions, and
help the child continue with developmentally appropriate tasks.
22
CASE
EXAMPLE
Twelve-year-old Anna survived an earthquake that killed several of her family members,
including her mother and grandmother. She appeared detached, with a fixed and
incongruous smile. Anna began to talk about her earthquake experiences. On the day
of the earthquake, her grandmother had come to their house to help her mother bake
a cake for Annas birthday. Suddenly the earth shook and the house collapsed on
top of them. Anna and her grandmother held on to each other under the collapsed
building for two days. She remembered her grandmothers constant prayers to God to
save her grandchild. In recounting this, Anna said, God, why didnt you take me away
with them? Is it because I am not good enough? You made me live and suffer and
remember everything. God, I love my mother even though I was teasing her when the
earthquake happened, telling her that I loved grandmother more than her. She had
difficulty falling asleep, nightmares about the earthquake, recurrent stomachaches,
and difficulty paying attention in class. She was ambivalent about her fathers plan to
remarry and saw herself as an obstacle to his finding a new wife. She confided in the
therapist that she felt obliged to keep smiling for the benefit of her father.
Information for Parents on Childhood Traumatic Grief can be found in the Appendices
on page 72.
HANDOUT
Parents and children may have had different levels of exposure to the circumstances
of the death and have experienced different levels of danger. Parents and children
might not both have been present at the scene of the death, they may have heard or
seen different details on the news, and may have learned of the death through different
means. They will also likely have had different relationships with the person who died
(e.g., spouse, sibling, or parent). Therefore their reactions and progress through
treatment can be different. There are times when parents reactions and symptoms
warrant different or more intensive individual treatment. Parents should be referred for
additional treatment either as an adjunct to the childhood traumatic grief parent-child
treatment being described here or once the parent-child treatment is completed.
23
MAIN
CONCEPT
For both the trauma- and bereavement-focused work, it is essential to be aware of,
and sensitive to, the familys personal and cultural beliefs and practices. This is
helpful for integrating personal beliefs into the treatment, knowing the origin and
accuracy of a childs beliefs, and planning for current and future bereavement-related
rituals and events. Certain topics or explanations for events may be common practice
in a particular culture, advocated by a family, and accepted by a particular child. Thus
there should be normalization for what is typical in a given cultural setting.
STRUCTURE OF TREATMENT
The training video and the following sections in the printed guide outline the general
structure, format, and treatment components of childhood traumatic grief treatment
as it is conducted with individual children school-age and older. This treatment has
typically been provided in 12-to-16 sessions each for the child and parent, with joint
sessions held at appropriate times. However, the length of time for the childhood
traumatic grief intervention can vary with the age of the child, severity of the problem,
and type of setting, thus requiring additional sessions. The individual treatment is
structured according to the following guidelines:
The child and parent are seen individually in their own sessions to allow for
freedom of expression. The work done in the child and parent sessions is
complementary. Having the parent in companion treatment allows the parent to
facilitate training and reinforcement of the childs newly learned skills, promote
understanding of issues, and increase communication between the child and the
parent. The child is engaged in specific skill-building, trauma, and memorializing
activities. The caregiver may be taught the same skills as the child, taught how
to help the child with new skills, and taught how to manage problem behavior.
At specified times, joint caregiver and child sessions are conducted. Following
careful preliminary planning, the child and caregiver engage in a shared activity
related to the story of the death and remembering the person who died.
In most situations it is suggested that the same therapist treat the child and
parent. In certain situations it may be preferable to have different therapists for
the child(ren) and parent(s) for example, when there are different levels of
exposure and intensity in the reactions, or when a parent is hesitant to bring
up personally significant issues to a therapist who is also treating the child.
Regardless of the number of therapists involved in the treatment, the case
should be conceptualized as a family case rather than as separate child and
adult cases. The individual child and parent sessions can be held consecutively
on the same or different days. When there is more than one child in treatment,
the same therapist works with each child in his own session but conducts only
one parent session where issues for all children are discussed. Children can
start treatment at the same time or the most symptomatic child may begin first.
24
Goals
1. Psychoeducation
2. Affect expression
25
Goals
5. Trauma narrative
6. Cognitive processing
Goals
26
TRAUMA-FOCUSED COMPONENTS 1 2 3 4 5 6
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
1. PSYCHOEDUCATION
T R E AT M E N T
COMPONENT
CHILD
CHILD
PA R E N T
PA R E N T
HANDOUT
27
TRAUMA-FOCUSED COMPONENTS 1 2 3 4 5 6
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
2. AFFECT EXPRESSION
T R E AT M E N T
COMPONENT
CHILD
ACTIVITY
Helping children with affect expression is an important next step in the treatment.
The goal is to have children identify or label a variety of feelings, pleasant ones as
well as those that make them uncomfortable or that they perceive to be bad. It is
important to explain that children should pay attention to their feelings and that
feelings are not good or bad. Certain feelings are more likely associated with the
trauma (e.g., helplessness), others to bereavement
(e.g., sadness), and others to everyday activities (e.g.,
annoyed). It is important for children to know the difference
between feelings and behaviors. All feelings are okay (e.g.,
feeling angry), but some behaviors (e.g., aggressive behaviors)
are not acceptable.
There are a number of therapeutic games and creative
activities that can be used to help children with this component. Children can add
facial expression to an outline of a face, decorate two sides of a mask to show
outside feelings visible to others and more private inside feelings, or pick songs that
portray different emotions. There are various games that also can be purchased that
focus on feelings identification. Once identified, it is important to also discuss what
situations accompany and cause different feelings and talk, draw, play, or act out
ways of coping with different feelings. A handout of different feeling faces can be
useful in helping children learn to identify various feelings.
See the resource list at the end of the guide for suggested games for purchase.
RESOURCE
PA R E N T
In addition to learning about their own emotions, it is essential that parents understand
the importance of the child being able to express his or her emotions. The goal is to
engage parents as partners in helping the child and support their role as coaches for
the childs newly learned skills. When unaware of the benefit of or meaning of a
childs expression of emotion, the parent may unknowingly discourage or even punish
the child. Parents should be accepting of the childs full range of emotions but
maintain discipline if the child engages in inappropriate behaviors.
Parents may also need to be taught appropriate ways to express their own emotions.
In particular, parents need to be coached to avoid exhibiting intense feelings of
distress in front of the child. It may be appropriate to explore the parents own feelings
related to the traumatic death at this time and suggest ways to monitor and modulate
their emotions and model appropriate expression (e.g., Its sad that Dad isnt here
to help make a snowman).
28
TRAUMA-FOCUSED COMPONENTS 1 2 3 4 5 6
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
CHILD
PA R E N T
Following feelings identification and regulation, it is impor tant to teach stressmanagement skills. These skills are used as the child confronts previously avoided
or uncomfortable thoughts and feelings experienced during and outside the sessions.
Stress-management skills are used to help children and parents manage unpleasant
physiological trauma reactions and symptoms, feel more in control, and cope
effectively with traumatic reminders. It is important to help children identify ways they
can soothe themselves when experiencing unpleasant or difficult feelings. Children
are encouraged to think about things they use or do that already help them; for
example, they can bring in CDs of songs that help them relax and feel happy, talk
about sports, or dance to relieve stress.
Some specific relaxation techniques that can be taught include:
ACTIVITY
Focused belly breathing: This Involves teaching the child to focus on breathing
rather than on anxiety symptoms. Children are taught to use diaphragmatic
breathing, slowly inhaling through the nose and exhaling through the mouth to
a count of three-to-five seconds. They can be helped by placing a cup or stuffed
animal on their stomach and instructed to make it go up and down. Older
children can imagine a balloon inside their stomach getting bigger and smaller
with each breath.
Progressive muscle relaxation: This involves alternating between tensing and
relaxing muscle groups and focusing on the different sensations associated with
tension and relaxation. Young children are often able to relax their bodies by
pretending to be a stiff piece of spaghetti that becomes a wet noodle or
a tin soldier who changes into a Raggedy Ann doll.
Progressive Muscle Relaxation scripts can be found in the Appendices on page 58.
HANDOUT
ACTIVITY
HANDOUT
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ACTIVITY
ACTIVITY
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
CHILD
PA R E N T
These skills are generally taught to both the parent and the child in the clinicians
office, and the child is encouraged to practice them at home The parent is instructed
to assist the child in practicing the strategies. Parents may also personally benefit
from using these strategies.
It may be necessary to explain the rationale for these techniques, as children and
parents may think they are simplistic or initially feel self-conscious. It may be useful
to use the analogy of a life preserver. Relaxation techniques are like a life preserver;
they help the child and parent to stay afloat until symptoms begin to diminish
over the course of treatment. When someone who cant swim falls into the water and
is drowning, its not the right time to teach him how to swim. Instead, it is better to
throw him a life preserver in order to keep him afloat until pulled out of the water.
Improving a childs ability to manage distressing affect is the focus of the next
strategy. This is also referred to as cognitive affect regulation, the goal being for
the child to use productive, age-appropriate responses to distress. The child is
taught ways to express and cope with distressing emotions, for example, counting
to 10 when angry, giving himself a time out, or doing some physical exercise
when upset.
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CHILD
PA R E N T
ACTIVITY
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
In order to help parents and children manage affect more effectively, it can be helpful
to explain the relationship among thoughts, feelings, and behaviors using the visual
metaphor of a triangle, referred to as the Cognitive Triangle. The source of some
distress may be the childs appraisal of danger, reactions to feeling threatened, and
attempts to be safe. It is important to explain how situations trigger certain distressing
and automatic thoughts, feelings, and behavior. This concept can be described in the
following manner:
Today we are going to talk about thoughts, feelings, and behaviors. In particular,
were going to talk about how our thoughts can affect the way we feel and then how
the way we think and feel can affect the way we behave. Thoughts are the things
we say to ourselves in our own head where nobody else can hear them. When our
thoughts make us feel good, it can affect our behavior; we
may want to smile or laugh. When our thoughts make us
feel bad, it can affect our behavior too; we may want to cry,
scream and shout, or hit somebody. It is helpful to understand
how thoughts, feelings, and behaviors are related and
especially important to figure out what thoughts make us
feel bad and how to help ourselves. A lot of times, people
can learn how to change what they think. They can choose
to think about things more positively and do things that can
make them feel better. (Paraphrased from Deblinger, D. &
Heflin, A. H. (1996). Treating sexually abused children and
their nonoffending parents: A cognitive behavioral approach. Thousand Oaks: SAGE
Publications, Inc.)
A Cognitive Triangle illustration can be found in the Appendices on page 64.
HANDOUT
ACTIVITY
HANDOUT
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2. A boy realizes he has a math test in three days and thinks, I dont know this
stuff very well, Im going to flunk (thought), which makes him feel fidgety and
hopeless (feelings), so he doesnt study (behavior). If he replaces it with I still
have plenty of time to learn this and do well (new thought), he will be optimistic
and determined (new feeling) and study extra hard (new behavior).
Thinking, feeling, behaving Test illustration can be found in the Appendices on
page 66.
HANDOUT
There are a variety of ways to introduce and teach these different skills and
techniques, and they can be modified for children at different ages. Some or all
of the techniques are also used according to the format of the treatment and the
age of the child (individual/group, toddler/teen).
It is necessary to establish these skills in preparation for the next phase of treatment.
Collectively, these first steps help children feel more confident about managing upsetting
thoughts and feelings. Having learned coping strategies, the child will be less fearful of
being overwhelmed or flooded by unpleasant emotions when creating the trauma narrative.
5. TRAUMA NARRATIVE
T R E AT M E N T
COMPONENT
DEFINITION
Most therapists who treat children already use many of the techniques that have
been presented. However, one part of this treatment may not be as familiar to some
therapists, because it involves encouraging children to directly recall and discuss their
most frightening memories. Learning which reminders are significant for the child allows
the therapist to prepare the child for managing unpleasant times, places, and reactions.
It is especially important to be mindful of any cultural taboos against such work.
A trauma narrative is the re-creation or retracing of the childs experience of someones
traumatic death, told in their own words, pictures, and even songs. By creating the story,
the child is carefully exposed to the traumatic elements of the death and gradually
becomes able to tolerate the more painful and disturbing aspects of the experience.
A childs sharing of the trauma narrative with a parent increases their mutual support.
The trauma narrative is typically developed gradually over several
sessions. We will often start by having the child describe something
about him or herself; this helps children feel more comfortable in
telling their story or writing their book. Then we have the child focus on
what life was like before the traumatic event that took the loved one
away. As the child comes closer to talking about the traumatic loss
through talking about less threatening aspects, he or she is more able
to engage in the process of gradually talking about more and more
upsetting aspects of the traumatic death itself. Judith Cohen
The Courage to Remember: Childhood Traumatic Grief Curriculum Guide
National Child Traumatic Stress Network
NCTSN.org
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MAIN
CONCEPT
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
A child with childhood traumatic grief typically avoids reminders of details associated
with the death, because they cause overwhelming and upsetting thoughts and
feelings. By confronting such feelings in a safe and controlled environment, while
also using the stress-reducing strategies and coping skills previously learned, the
child is better able to tolerate trauma-related thoughts and feelings about the death.
Children (and adults) are often resistant to the idea of creating a trauma narrative.
It is typically distressing for people to remember traumatic events in detail. Therefore,
it is often necessary to provide a rationale. Creating a trauma narrative can be
compared to removing a splinter from your finger. The splinter likely hurts, but people
resist taking the splinter out with a needle or tweezers because they think it will hurt
too much. However, if the splinter is left in, the finger could become infected, the
person could get sick, and it will be more difficult to treat. Therefore, its better to
remove the splinter as soon as possible, knowing that a small amount of pain early
prevents more problems and promotes healing. Then it is discussed that creating a
trauma narrative is like pulling out the splinter. Even though it is a little painful, it is
the best way for the person to heal from his or her traumatic experience.
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The trauma narrative should focus as much as possible on various sensory details
(i.e., sights, sounds, smells, tastes, and tactile sensations) that the child associates
with the traumatic death. It is important to expose the child to the details as he has
remembered them, because they often serve as powerful reminders of the trauma
and triggers for symptoms.
CHILD
Building the trauma narrative takes time and should be done over a number of sessions.
It should begin gradually with a conversation about less threatening details about the
traumatic death and the person who died. When discussing the actual death the first
time through, it may be helpful to focus on a factual account (e.g., who, what, when,
where, how) of the traumatic event, without asking about the childs thoughts and
feelings about the detail. When developing the factual account, it is not important that
the narrative be perfectly accurate, but major discrepancies should be addressed.
After the factual account has been created, the clinician should then go back through
the narrative with the client and ask questions about how the child felt, and what he
was thinking about during certain aspects of the traumatic event. It is important to be
careful to monitor the childs distress while creating the trauma narrative and help the
child use the skills he learned prior to making the trauma narrative in order to handle
any distress that occurs while making the narrative. The goal is to have the childs
distress decrease over time, with continued exposure to the trauma narrative.
ACTIVITY
The child develops the trauma narrative jointly with the therapist through a series of
carefully guided questions. The initial trauma narrative may be brief, but it provides
anchor points that can be used in discussion to help the child elaborate on the details.
There are a variety of ways a child can create a trauma narrative. In addition to writing,
some children may prefer to document their story in other ways, such as by writing a
play, composing a song, play acting, or making a video. The child can be guided to
create the trauma narrative by engaging in a conversation or asking questions such as
the following:
Background for the Trauma Narative
Tell me a bit about yourself and about school.
What you like to do in your free time; do you have any favorite hobbies?
What kinds of things did you and your dad do together?
Beginning the Trauma Narative
It would helpful for me to hear what it was like the day your mom died.
Do you remember anything specific about the weather that day?
What is the first thing you remember about your moms death?
I would like to know more about what it was like when you first found out
your dad had cancer.
All stories have a beginning; how does the story about your grandmas death start?
The Courage to Remember: Childhood Traumatic Grief Curriculum Guide
National Child Traumatic Stress Network
NCTSN.org
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RESOURCE
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CHILD
PA R E N T
CHILD
PA R E N T
JOINT
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
In addition to creating the trauma narrative with the child, the therapist talks to the
child about sharing the trauma narrative with the parent. The child is told the
importance of being able to communicate openly and honestly and share thoughts
about the death and the deceased. The therapist will be reading the trauma narrative
to the parent without the child at first, prior to their joint meeting. In addition, the
therapist prepares the child for a joint session by talking about parts to focus on
and obtaining any particular questions the child would like the parent to ask.
The parent should be prepared for the joint session with the child in which the trauma
narrative is presented. This provides an opportunity for the parent to appreciate the
childs unique experience. While the child is creating the trauma narrative, the therapist
shares what the child is creating as it is being developed. This allows the parent to
respond in private to the trauma narrative and plan for an appropriate response in the
presence of the child.
Once completed by the child, ideally the trauma narrative is then shared with the
parent, again according to carefully guided steps to prepare both child and parent for
the details that will be presented and any possible emotions. Reading the story
together and talking about it in a structured way helps the parent and child effectively
communicate about the upsetting circumstances of the death.
Some of preliminary work that should be done before the joint session includes the
following:
ACTIVITY
Having the child practice reading the narrative aloud to the clinician.
Discussing and addressing any concerns that the child may have about sharing
the trauma narrative with her parents (e.g., What if they get angry?).
Discussing and addressing any concerns that the parent may have about
listening to the childs trauma narrative (e.g., What if I get really upset?
What do I say to her?).
Explaining, to the parents the rationale for having the child share the trauma
narrative with them (e.g., Your child looks to you for support, and you can be a
role model for how to cope and talk about the death.)
Preparing parents to be supportive, attentive listeners.
Gradually exposing the parents to aspects of the trauma narrative prior to having
the child share it with them to help desensitize the parent to the content of the
trauma narrative.
Training the parent to talk about the death and the person who died, express
appropriate emotions, and model effective coping when listening to the TN.
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What was helpful to Hannah in treatment was the story that she got to
tell about her grandmothers death. Because until then, I dont think she
was able to express what she envisioned her grandmothers death was
all about. She heard us discuss it, we discussed it with her in our terms,
but I dont think she understood exactly, she wasnt able to express
exactly what she thought, and the story gave her an opportunity to
understand what grandmommy might have been looking like while she was
dying in bed. Hannah had a vision in her head as to what this all looked
like that no one else shared, so for her to be able to draw this and talk
to somebody about this was very very helpful. I think it gave her more
permission to remember her without feeling so much pain because one of
her pictures was a great picture, at the end of the story where shes
smiling on the ground, and she sees grandmommy up in the clouds with
a big smile, an angel smiling down on her. I think she felt safer. Parent
6. COGNITIVE PROCESSING
T R E AT M E N T
COMPONENT
CHILD
As the trauma narrative is being created, the therapist is able to identify thoughts and
beliefs about the traumatic event that are inaccurate or not helpful. These are often
tied to feelings of responsibility for the death and related feelings of helplessness. It
is extremely difficult for the child or parent to feel he could have done something to
prevent the death and especially complex if there is any way the child or parent could
have changed the outcome.
Once the narrative is completed, cognitive processing is the final component of the
trauma-related portion of the treatment and is used to modify and correct these
thoughts and beliefs.
The following are example questions for the child that may be helpful in eliciting
distortions:
ACTIVITY
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ACTIVITY
Unhelpful beliefs may be totally false, such as thinking my brother died because I
was bad. Unrealistic thoughts such as I should have stopped the bad man from
hurting my mom are also unproductive and harmful. Other thoughts may be accurate
but unhelpful, for example, when a child thinks people who are burned in a fire are in
terrible agony. When attempting to handle feelings of helplessness, children may feel
a need or begin to take on excessive responsibility. Ways to tolerate and address such
feelings can also be addressed. After a childs specific trauma-related cognitions and
beliefs have been identified, the therapist and the child begin to evaluate and correct
them. This can be accomplished through the use of such techniques as the following:
Progressive logical questioning: For example, So youre saying that you should
have stopped that guy from shooting your mom? How big was that guy? And how
big are you? So he probably weighed about 200 pounds and you weigh about
60 pounds? Is there really any way that a 60-pound kid could stop a 200-pound
guy from doing something like that?
Best-friend role-plays: For example, What would you tell your best friend if he told
you that he believed that he should have stopped the guy from shooting his mom?
Therapist-child role reversal: For example, Im going to pretend to be you, and
I want you to pretend to be a therapist. Im going to tell you some things that
youve told me you think about. I want you to say what you think a therapist
would say about those things.
Corrective mantras: These may be more suitable for younger children who are less
able to engage in cognitive processing. The therapist may provide them with corrective
mantras such as I did everything I could to help my mom. The child practices
repeating the mantra when he finds himself thinking about the traumatic event.
Cognitive processing should also be done with the parent regarding his or her
own thoughts.
PA R E N T
CASE
EXAMPLE
A mother thinks she should not have fought with her husband before he shot himself.
When asked what the fight was about, she explained that she told him that she did
not like the way he coped with losing his job. His getting drunk every night did not
solve anything and made things worse. She told him to see a therapist because he
seemed depressed. She says I should have just left him alone and he wouldnt have
killed himself. The therapist reframed this, saying that the wife recognized his
depression and that alcohol was making the depression worse. She saw he needed
help and offered him support, doing everything she could have done to help him. The
therapist helps her to see that he was not in his right mind when he was depressed
and drunk. He killed himself for these reasons, not because she suggested he get help.
The Courage to Remember: Childhood Traumatic Grief Curriculum Guide
National Child Traumatic Stress Network
NCTSN.org
38
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GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
CHILD
When the trauma symptoms recede as a result of the prior trauma-focused sessions, the
child is better able to address issues related to death. However, the child may still be
hesitant to talk about the death of a loved one due to societal taboos surrounding
the topic of death and/or the parents own discomfort in talking about death. The
practitioner should know of any prohibitions against talking about those who die and
know any culturally specific terminology that is used when guiding the discussion.
Many adults feel uncomfortable talking about death due to their own confusion and/
or grief and may therefore send subtle (or not so subtle) messages to children about
remaining silent. Consequently, it is helpful to begin this phase by having the child
openly communicate about death in session with the therapist. The goal is to educate
the child about death, have the child become comfortable talking about death, and
have the child ask questions to develop a clear understanding of death. The activities
below can encourage more open discussion. After talking about death in general, the
child will be more prepared to talk directly about his or her own bereavement.
ACTIVITY
RESOURCE
REFERENCE
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TRAUMA-FOCUSED COMPONENTS 1 2 3 4 5 6
CASE
EXAMPLE
CASE
EXAMPLE
PA R E N T
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
A seven-year-old child and her therapist are reading a book about death and come
across a particular sentence: Every living thing dies. Once it dies it can never come
back to life again. About two minutes later, several pages after this section, the little
girl says, I didnt know that. When the therapist asks what she means, the girl says,
I didnt know that you couldnt come back alive again. This highlights the value of
communication about death and how direct discussion helps identify and correct
cognitive distortions.
Younger children may be preoccupied with more concrete questions or concerns
regarding the physical body of the deceased person. For example, a six-year-old child
asked how her deceased father would be able to go to the bathroom if he could not
get out of the coffin. These questions might be brought to light only if the child is
given the opportunity to voice his or her concerns, again emphasizing the need for
open communication regarding the death.
This is a good time to assess the parents ability to talk about death in general as
well as his or her own loss. It may be necessary to revisit and stress the importance of
talking about the loss, particularly if the parent seems hesitant to do so. In addition,
it is important for the therapist to have a good understanding of the parents religious
and cultural beliefs surrounding death and
grieving to ensure that the therapist does not
inadvertently give the child any conflicting
information. Finally, the therapist should
ascertain the parents own perception of
the childs understanding of death. Parents
may be confused or upset about the fact
that a child is not showing strong emotions
about the death. However, parents may
be more empathic toward the child if they
understand that the childs nonemotional
response may be due to developmental
limitations with regard to the childs ability
to comprehend the permanence of death.
The child may also be attempting to shield the parent from the childs own sadness,
which may be an important area to explore with the child and parent together.
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CHILD
ACTIVITY
PA R E N T
Mourning the loss encourages and supports the child in acknowledging what has been
lost by the persons death.
Its important for the child, in order to accept the magnitude of the
loss, to be able to name these things that theyve lost. Judith Cohen
The process may begin with an activity focusing on the characteristics of the person
who died. This can be done by writing a new bereavement book or even drawing
pictures, guiding the child with prompts or questions similar to the process used for
creating the trauma narrative. As the child becomes more comfortable talking about
the person, she is encouraged to list or describe things she will miss sharing with the
person in the future. These can include things that the deceased person and the child
did for each other, including basic caregiving activities as well as unique aspects of
the relationship. This is a good time to talk about anticipating loss reminders,
particularly if the activities that the child used to do with the deceased are now
triggering posttraumatic reactions. Next, using the letters of the persons first name,
the child creates an anagram, attaching a characteristic of the person to each letter.
The child is encouraged to identify which characteristics he or she will miss the most.
By helping children talk about the deceased, rather than avoid the topic, the child
and therapist will be better able to anticipate painful situations that may arise and
prepare accordingly.
The therapist should discuss with the parent what the child has been writing and/or
talking about with regard to the things the child has lost. This will likely precipitate
feelings of great sadness for the parent given that the parent will be grieving his or
her own losses in addition to the childs losses. These feelings should be normalized
by the therapist. In addition, the therapist should help the parent to generate ways
in which the child may optimally be able to deal with loss reminders in the future
(e.g., the parent may wish to attend all of the childs football games that the childs
deceased father used to attend).
The therapist can also point out the ways in which the parents own grief responses
may be contributing to the childs bereavement process. For example, if the parent
makes every effort to avoid the topic of the deceased person, it is likely that the child
will hold in his or her emotions. On the other hand, if the parent becomes overtly
distraught at the mention of the deceased persons name, the child may also choose
to avoid talking about the deceased in an effort to protect the parent. The therapist
should help the parent to support the childs expression of emotion, while at the
same time find ways of helping the parent to receive the support that he or she needs.
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CHILD
Another bereavement task involves acknowledging and accepting any ambivalent feelings
about the deceased. As with most relationships, the child has likely experienced
some unpleasant aspects, even if the majority of interactions with the deceased were
positive. However, if the relationship was highly ambivalent prior to the death, or if the
death occurred in a way that is stigmatizing, such as suicide, the childs feelings of
grief can be even more difficult to express.
In particular, the child may feel guilty about having negative feelings such as shame
or anger toward the deceased, and may think it means he or she didnt really love
the deceased person. Or, particularly in the case of a suicide, the child may blame
himself or herself for the death in some way (e.g., If I had only behaved better, Mom
wouldnt have wanted to kill herself). This may lead to feelings of abandonment as
well as concerns regarding the deceased persons true feelings toward the child.
Therefore, an important role of the therapist is to help the child to understand that
it is normal to have both positive and negative feelings toward the deceased by
encouraging expression of all feelings about the person.
There might have been some aspects of the relationship that
werent always that positive. For example, you might have a child
who loved her dad who died in tragic circumstances, but perhaps
the dad never spent any time with her. Anthony Mannarino
ACTIVITY
CASE
EXAMPLE
PA R E N T
One useful technique in this process is having the child write a letter to the deceased,
in which he describes a range of feelings. The child also writes a letter that the
deceased would write back if he could. This can help the child to express feelings that
he or she may not have verbalized and also provide a sense of closure for the child.
The father of a 14-year-old girl died of a drug overdose. She was angry about how
his lifestyle created such heartache for her mother, and she was ashamed of how he
died. She expressed these feelings in her imaginary letter to her father. In the letter
she composed as a response from him, he revealed that he was sorry for the pain
he had caused and that he could never forgive himself for having his illness interfere
with his ability to show her how much he truly loved her.
In many cases, the parent may idealize the deceased person, which may preclude
the child from fully expressing any negative feelings about the deceased. Therefore,
it is important for the therapist to help the parent understand the childs perspective
and address any dissonance between the parents and childs respective beliefs
about the deceased person. However, given that the idealization of the deceased
person is not necessarily harmful, caution should be used in correcting the childs
or the parents overly positive view of the deceased. Instead, the best approach is
to encourage the parent to validate the childs perspective and to focus on ways of
helping the child to resolve any unfinished business with the deceased.
The Courage to Remember: Childhood Traumatic Grief Curriculum Guide
National Child Traumatic Stress Network
NCTSN.org
42
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GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
CHILD
ACTIVITY
PA R E N T
CHILD
PA R E N T
JOINT
This task is often a necessary prerequisite for helping children to give themselves
permission to engage in new relationships. Different exercises are used to help
children preserve positive feelings and memories of the deceased person.
In order to successfully grieve the loss of a loved one, its
important for the child to convert the relationship from one of
interaction to a relationship that is based on memory, not current
interaction. Judith Cohen
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CHILD
ACTIVITY
PA R E N T
This bereavement task is designed to help children accept that the relationship with
the deceased has changed from one of interaction to one of memory.
One technique that is often used to exemplify this change is a drawing of two balloons
one that is anchored to the ground and the other that is floating toward the sky.
The child identifies things that she has lost in the relationship, such as going to
baseball games together, and writes them in the floating balloon. The child also
identifies things that remain in the relationship with the deceased, such as memories
of fun times spent with the deceased and writes them in the balloon on the ground.
This helps children to understand that although some aspects of the relationship have
changed, their positive memories can serve as the foundation for a new and different
relationship with the person who died.
The child will likely need the parents permission to let go of the interactive relationship
with the deceased, given that many children feel guilty or disloyal in doing so. The
parent may need assistance in understanding the importance of this task and working
through any resistance that he or she may have. The therapist can review specific
ways in which the parent can help the child to redefine his or her relationship with
the deceased. For example, parents may wish to be more cognizant of the language
they use to talk about the deceased (e.g., referring to the person in the past as
opposed to the present).
CHILD
ACTIVITY
The goal of this task is to have the child identify and discuss what has changed in
his or her life since the death and the difference between a real previous relationship
and a new relationship with the person in ones memory, and then engage in new
relationships. Following the death of a loved one, children may be reluctant to engage
in new relationships. They may feel that they are being disloyal to the deceased loved
one if they form new relationships or that no other person will ever be able to make
up for the loss of the loved one. It is important to help the child realize that if he or
she forms new relationships it does not mean he or she loves the new person more
than the person who died. Also, the child may need assistance coming to the
realization that, although new relationships will be different than the relationships with
the deceased, it is not a competition, and the new relationships can be satisfying.
One way to help a child develop new relationships is to begin by identifying, in a list,
the things that he or she used to do with the deceased person. Next the child writes
in names of people who could fill those roles left empty by the deceased.
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PA R E N T
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
This may be a particularly difficult task for parents if they are struggling with their
own ability to move forward and develop new relationships. The therapist may need
to spend some time discussing the parents own concerns/fears in this regard. The
therapist may also need to provide psychoeducation regarding the importance of
parental modeling of the development of new relationships and a strong future
orientation. Parents should not only be encouraged to maintain and develop important
relationships for themselves, but they should also be encouraged to praise their
children for developing new relationships. This can help to relieve any guilt that the
child may have for spending time with other people or leaving the parent by himself
or herself.
CHILD
Making meaning of the death is a bereavement task that encourages children to view
their traumatic experience as one that, while difficult and painful, has helped them to
grow or become stronger in some way. If the child felt helpless due to fearing for his
life as well, e.g., having survived a hurricane in which a younger sister died, engaging
in an activity to make the world a better or safer place is constructive.
You want to help children develop some meaning about the death.
Its not to turn it into a positive experience, but you want them to
realize they may have learned things about themselves, about other
people, or may learn that theres a way to help other kids that are
in this same situation. Robin Goodman
ACTIVITY
Some specific techniques involve asking children to talk about what they have
learned about themselves or the world around them as a result of the death. Some
children may have learned they are stronger than they thought, while others may have
learned they have many people to count on for help. Some children find meaning in
their loss by helping other children who are going through similar situations, perhaps
by being a mentor or volunteer or helping to prevent the type of traumatic loss that
they experienced by joining a group like Students Against Drunk Driving. These
activities can often help children to find meaning in the face of tragedy. Children
are encouraged to look at what was learned from the death, at how the experience
can help the child help others.
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TRAUMA-FOCUSED COMPONENTS 1 2 3 4 5 6
CHILD
PA R E N T
JOINT
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
The parent can help the child by pointing out ways in which the child has changed
for the better or grown in some way since the loss. The parent can also offer
suggestions for ways in which the child may be able to help others as a result of his
or her painful experience.
CHILD
PA R E N T
JOINT
PA R E N T
It is important to help the child and family with the three Ps of grief. Children and
families can be helped to predict difficult times in the future. For example, if the
childs father usually accompanied her to her basketball games, it may be difficult for
the child to return to those games without him. Accordingly, the family should prepare
for future trauma and loss reminders. The therapist can help the family to strategize
about ways of making those reminders or difficult times easier to deal with. It is also
necessary to give permission to oneself both the child and family to have
different feelings about the trauma and death as time goes by.
When talking with the parent about the evolution of grief, it is best to keep the
perspective of the entire family in mind. Parents should be helped to develop an
understanding of the family members as individuals and the family as a whole. This
should be done by exploring and addressing various issues as they relate to the
specific death as well as to current family life and future experiences. In particular,
46
TRAUMA-FOCUSED COMPONENTS 1 2 3 4 5 6
GRIEF-FOCUSED COMPONENTS 7 8 9 10 11 12 13 14
attention should be paid to the impact of the following issues on the individuals and
on the family:
individuals different trauma and loss reminders
individuals different experiences of the death and previous traumatic losses
individual differences in the course of trauma and grief
individuals different roles in the family
developmental differences among all the individuals
cultural differences
generational differences
the different stages in the familys life
the functioning of the family system
The parents should encourage mutual respect and support among the family
members for their own grief issues and develop a family focused plan for managing
future grief and trauma related reminders and activities.
ACTIVITY
CHILD
PA R E N T
JOINT
One helpful activity is to create a perpetual calendar (with months and dates but no
specific year). The child and/or parent identify times and dates of the year that will
be more difficult, looking for patterns such as a time of year that is more stressful.
Dates that will recur such as the deceaseds birthday are indicated with one symbol
or color and occasions that are one-time events, such as a first day of school, can
be indicated with another symbol or color. The individual is helped to make plans
for coping with the stressful time and feelings, such as using good self-care, or
creating new alternative rituals. This exercise also emphasizes to the family that
difficult times will happen in the future, not just in the coming year, and helps them
learn ways to process and brainstorm ways to cope with those hard times.
Termination requires its own specific attention. It is important to address the ways
in which terminating treatment with the therapist (whom can be called upon again) is
different from a relationship that ends because of a death. For children and parents,
this can be a good opportunity to talk about different kinds of losses and generate
ways of coping with those difficult experiences. This is also a good time to review all
of the progress that both the child and the parent have made, and for the therapist to
offer praise for their tremendous effort. It is important for the therapist to remind the
parent and child that difficult times may arise again, particularly during life transitions,
and that therapy is always an option in the future, even if only used as a booster
session. In addition, if the clinician believes the child or parent continues to have
troubling symptoms or difficulty with usual activities, additional treatment may be
warranted. It may be helpful to recommend additional trauma- or grief-focused
treatment or a different type of treatment.
47
RESOURCE
Detailed instruction on work with toddlers and young children can be obtained at:
Lieberman, A. F., Compton, N. C., Van Horn, P. & Ghosh Ippen, C. (2003) Losing a
parent to death in the early years: Guidelines for the treatment of traumatic
bereavement in infancy and early childhood. Washington, DC: Zero to Three Press.
48
Both individual and group-based treatment address the trauma and grief-related aspects of
childhood traumatic grief. However, a group-based treatment may be especially appropriate
for adolescents. In addition to being cost effective, trauma- and grief-focused groups
are beneficial in a number of specific ways. For example, groups provide and encourage
normalization and validation of emotions,
direct member-to-member feedback and interaction,
exposure to other members experiences,
opportunities to offer positive and constructive feedback,
peer support, and
mutual understanding between members.
MAIN
CONCEPT
Group work can result in a member feeling less isolated or estranged, and it can impact
issues related to the adolescents emerging self-concepts, feelings of shame and
guilt, and the desire for revenge. For example, group therapy allows members to give
constructive and positive feedback, which can assist in increasing group cohesion and
treatment effectiveness. Member-to-member interactions can be a highly influential
tool for challenging and replacing maladaptive beliefs, such as pessimistic expectations
and cognitive distortions. Group treatment also makes use of the helper-therapy
principle, wherein the chance to help others with a similar problem serves as a catalyst
for personal change. That is, helping others allows members to help themselves by
strengthening their self-concept, self-esteem, self-confidence, and interpersonal skills.
Group work enriches members capacities to give and receive support and to speak
authentically and genuinely about their experiences. When others talk about their
feelings in similar situations, feelings are validated. They develop and practice social
skills to help them select with whom, when, and how much of their experience to
disclose. These skills help them to be self-protective, maintain closeness to selected
others, and recruit support from others when confronting distressing reminders and
difficulties. The supportive transactions that follow can greatly help members to
challenge and change their pessimistic beliefs that no one cares, that no one can
understand what they have been through, that others will reject them if they shared
their feelings and experiences, or that no one can really help them deal with the
serious problems they face.
MAIN
CONCEPT
The skill set of a well-trained group therapist will overlap with, but are independent
from, the skill set of a competent individual therapist. Importantly, the interaction of
group members serves as the most direct mechanism of change; the group itself
serves as the primary vehicle of change, and the group leaders serve as the indirect
agents of change. Hence, skilled group leaders provide a therapeutic structure and
facilitate interactive processes.
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The goals of group-based and individual-based childhood traumatic grief treatment are
similar. These include
reducing the frequency, intensity, and degree of interference associated with
childhood traumatic grief reactions, including trauma-related symptoms,
depressive reactions, and grief reactions;
enhancing effective coping and positive adaptation in relation to distressing
reminders and grief-related adversities;
enhancing the ability of youth to access high-quality social support from others;
and
reducing trauma-related developmental derailment and encouraging engagement
in normal developmental tasks.
As with individual treatment, one focus of the group-based treatment is on the
traumatic experiences.
ACTIVITY
ACTIVITY
ACTIVITY
Intervention strategies focus on the seven major areas in which disruption is likely to
occur: school performance, peer relationships, family relationships, living conditions,
health problems, economic prospects, and neighborhood/community environment.
Additional areas are more grief-related and focus on acceptance, adaptation, and
coping with life changes and losses and training in communication skills to enhance
support-seeking. As appropriate, direct intervention is also carried out at the family,
community, and/or national levels to reduce or remove unnecessary adversities.
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An additional therapeutic focus is bereavement and the interplay of trauma and grief.
In particular, intrusive distressing traumatic images, emotional numbing, and cognitive/
behavioral avoidance associated with traumatic death may interfere with normal grief
reactions, including reminiscing and establishing a memory-based psychological
relationship with the deceased.
ACTIVITY
ACTIVITY
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CASE
EXAMPLE
MAIN
CONCEPT
The therapist should introduce the group by explaining the special nature of the group.
For example: This group is designed to help you become more aware of your trauma
and grief reactions. As you share more as a group about the difficulties you experience,
you give the gift of telling your fellow group members that they are not alone. It takes
courage to share this kind of personal information. Working together will also help you
be more aware, not only of ways in which other people can support you so that you
can deal better with your problems and feel better, but also of ways in which you can
support other people. So, youll be practicing the skills of both giving support and
receiving support. In the group everyone is on a level playing field.
The four basic treatment modules are described briefly below. The approximate
number of session for each is identified. However, keep in mind that the length of
time varies due to such things as number of members in the group and the nature of
issues that arise during the group. As with all treatments, leaders should be flexible
in adjusting the activities and number of sessions to meet the needs of the group.
Module 1: Up to six sessions. In the beginning of treatment, the goal is to develop
group cohesion and a positive group identity. Psychoeducation about childhood
traumatic grief is used. Interventions are also aimed at developing adaptive coping
skills (e.g., cognitive coping, affect management, and developing a plan to cope
with trauma reminders before, during, and following there occurrence). Social
support and support-seeking skills are also important to develop in this beginning
stage, in order to lay a strong foundation for the later trauma- and grief-focused work.
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53
CONCLUDING THOUGHTS
RECOGNIZE, RESPOND, REMEMBER
For clinicians who are unfamiliar with childhood traumatic grief,
it would be important to recognize that childhood traumatic grief
includes traumatic stress symptoms and that these symptoms
interfere with the childs ability to go through the normal steps of
the bereavement process. Anthony Mannarino
Things to look for include children who do not talk about their lost
loved one, who avoid reminders such as going to the grave site,
who do not want to remember or memorialize the person who died,
and children who are very avoidant of talking about not only the
death and the cause of death but also the loved one. Judith Cohen
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Using The Courage to Remember video and curriculum is the first step in developing
your skills at helping children with childhood traumatic grief. Although presented as a
specific structured intervention, treatment should always be adapted to the individual
childs family and situation. Further training and supervision is recommended. This
work is challenging and rewarding. You should be mindful of your own experiences and
reactions to trauma and bereavement as it informs you work, and seek out your own
support if necessary.
We need to know that children always remember; the question is
how they remember. For this reason, its very important to help a
child translate visceral memories of fear and anger into cognitive
memories so that the child can be helped to develop coping
mechanisms for feelings that are overwhelming in order to help
them become modulated and under control. Alicia Lieberman
One of the best things you can do for these children is help them
realize its OK to remember the way the person died as well as who
the person was. Robin Goodman
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APPENDICES
HANDOUTS, RESOURCES, REFERENCES
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Feeling Faces
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58
59
PMR Script 2
Suggested for children ages 5 through 8 years old. (Koeppen, 1974)
Hands and Arms
Pretend you have a whole lemon in your left hand. Now squeeze it hard. Try to
squeeze all the juice out. Feel the tightness in your and arm as you squeeze. Now
drop the lemon. Notice how your muscles feel when they are relaxed. Take another
lemon and squeeze it. Try to squeeze this one harder than you did the first one.
Thats right. Real hard. Now drop your lemon and relax. See how much better your
hand and arm feel when they are relaxed. Once again, take a lemon in your left hand
and squeeze all the juice out. Dont leave a single drop. Squeeze hard. Good. Now
relax and let the lemon fall from your hand. (Repeat on right side.)
Arms and Shoulders
Pretend you are a furry, lazy cat. You want to stretch. Stretch your arms out in front
of you. Raise them up high over your head. Way back. Feel the pull in your shoulders.
Stretch higher. Now just let your arms drop back to your side. Okay, kitten, lets
stretch again. Stretch your arms out in front of your. Raise them over your head. Pull
them back, way back. Pull hard. Now let them drop. Good. Notice how your shoulders
feel more relaxed. This time lets have a great big stretch. Try to touch the ceiling.
Stretch your arms way out in front of you. Raise them way up high over your head.
Push them way, way back. Notice the tension and pull in your arms and shoulders.
Hold tight, now. Great. Let them drop very quickly and feel how good it is to be
relaxed. It feels good and warm and lazy.
Shoulders and Neck
Now pretend you are a turtle. Youre sitting out on a rock by a nice, peaceful pond,
just relaxing in the warm sun. It feels nice and warm and safe here. Oh-oh! You sense
danger. Pull your head into your house. Try to pull your shoulders up to your ears and
push your head down into your shoulders. Hold in tight. It is not easy to be a turtle in
a shell. The danger is past now. You can come out into the warm sunshine, and once
again, you can relax and feel the warm sunshine. Watch out now! More danger. Hurry,
pull your head back into your house and hold it tight. You have to be closed in tight to
protect yourself. Okay, you can relax now. Bring your head out and let your shoulders
relax. Notice how much better it feels to be relaxed than to be all tight. One more
time, now. Danger! Pull your head in. Push your shoulders way up to your ears and
hold tight. Dont let even a tiny piece of your head show outside your shell. Hold it.
Feel the tenseness in your neck and shoulders. OK. You can come out now. Its safe
again. Relax and feel comfortable in your safety. Theres no more danger. Nothing to
worry about. Nothing to be afraid of. You feel good.
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Jaw
You have a giant jawbreaker bubble gum in your mouth. Its very hard to chew. Bite
down on it. Hard! Let your neck muscles help you. Now relax. Just let your jaw hang
loose. Notice how good it feels just to let your jaw drop. OK, lets tackle that
jawbreaker again. Bite down. Hard! Try to squeeze it out between your teeth. Thats
good. Youre really tearing that gum up. Now relax again. Just let your jaw drop off
your face. It feels so good just to let go and not have to fight that bubble gum. OK,
one more time. Were really going to tear it up this time. Bite down. Hard as you can.
Harder. Oh, youre really working hard. Good. Now relax. Try to relax your whole body.
Youve beaten the bubble gum. Let yourself go as loose as you can.
Face and Nose
Here comes a pesky old fly. He has landed on your nose. Try to get him off without
using your hands. Thats right, wrinkle up your nose. Make as many wrinkles in your
nose as you can. Scrunch your nose up real hard. Good. Youve chased him away.
Now you can relax your nose. Oops, here he comes again. Right back in the middle of
your nose. Wrinkle up your nose again. Shoo him off. Wrinkle it up hard. Hold it just
as tight as you can. OK, he flew away. You can relax your face. Notice that when you
scrunch up your nose that your cheeks and your mouth and your forehead and your
eyes all help you, and they get tight too. So when you relax your nose, your whole face
relaxes too, and that feels good. Oh-oh, this time that old fly has come back, but this
time hes on your forehead. Make lots of wrinkles. Try to catch him between all those
wrinkles. Hold it tight, now. OK, you can let go. Hes gone for good. Now you can just
relax. Let your face go smooth, no wrinkles anywhere. Your face feels nice and
smooth and relaxed.
Stomach
Hey! Here comes a cute baby elephant. But hes not watching where hes going.
He doesnt see you lying there in the grass, and hes about to step on your stomach.
Dont move. You dont have time to get out of the way. Just get ready for him. Make
your stomach very hard. Tighten up your stomach muscles real tight. Hold it. It looks
like he is going the other way. You can relax now. Let your stomach go soft. Let it be
as relaxed as you can. That feels so much better. Oops, hes coming this way again.
Get ready. Tighten up your stomach. Real hard. If he steps on you when your stomach
is hard it wont hurt. Make your stomach into a rock. OK, hes moving away again. You
can relax now. Kind of settle down, get comfortable, and relax. Notice the difference
between a tight stomach and a relaxed one. Thats how we want to feel nice and
loose and relaxed. You wont believe this, but this time hes really coming your way
and no turning around. Hes headed straight for you. Tighten up. Tighten hard. Here
he comes. This is really it. Youve got to hold on tight. Hes stepping on you. Hes
stepped over you. Now hes gone for good. You can relax completely. Youre safe.
Everything is okay, and you can feel nice and relaxed.
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This time imagine that you want to squeeze through a narrow fence and the boards
have splinters on them. Youll have to make yourself very skinny if youre going to
make it through. Suck your stomach in. Try to squeeze it up against your backbone.
Try to lie as skinny as you can. Youve got to get through. Now relax. You dont have
to be skinny now. Just relax and feel your stomach being warm and loose. OK, lets
try to get through that fence now. Squeeze up your stomach. Make it touch your
backbone. Get it real tight. Get as skinny as you can. Hold tight, now. Youve got to
squeeze through. You got through that skinny little fence and no splinters. You can
relax now. Settle back and let your stomach come back out where it belongs. You can
feel really good now. Youve done fine.
Legs and Feet
Now pretend you are standing barefoot in a big fat mud puddle. Squish your toes
down deep into the mud. Try to get your feet down to the bottom of the mud puddle.
Youll probably need your legs to help you push. Push down, spread your toes apart,
and feel the mud squish up between your toes. Now step out of the mud puddle.
Relax your feet. Let your toes go loose and feel how nice that is. It feels good to be
relaxed. Back into the mud puddle. Squish your toes down. Let your leg muscles help
push your feet down. Push your feet. Hard. Try to squeeze that mud puddle dry. OK.
Come back out now. Relax your feet, relax your legs, relax your toes. It feels so good
to be relaxed. No tenseness anywhere; you feel kind of warm and tingly.
Conclusion
Stay as relaxed as you can. Let your whole body go limp and feel all your muscles
relaxed. In a few minutes I will ask you to open your eyes, and that will be the end
of this session. As you go through the day, remember how good it feels to be relaxed.
Sometimes you have to make yourself tighter before you can be relaxed, just as we
did in these exercises. Practice these exercises every day to get more and more
relaxed. A good time to practice is at night after you have gone to bed and the lights
are out and you wont be disturbed. It will help you get to sleep. Then when you are a
really good relaxer, you can help yourself relax at school. Just remember the elephant,
or the jaw breaker, or the mud puddle, and you can do your exercises and nobody will
know. Today is a good day. Youve worked hard in here, and it feels good to work hard.
Very slowly now, open your eyes and wiggle your muscles around a little. Very good.
Youve done a good job. Youre going to be a super relaxer.
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64
Cafeteria
65
Test
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The doctor came in. I forget what he said. My mom and dad were squeezing me.
The doctor said she died. I felt very sad. My mom and dad were crying. I never saw
Kelsey, but my mom got to hold her. That really stinks. I feel mad that I didnt see her
or hold her or hug her or kiss her or even get to say good bye to her. My mom and
dad stayed and my Aunt Kathy and Gramma took me to Ericas house. I was very sad.
Daddy went to hold Kelsey and Mommy went to be with me. We sat together. Mommy
went back to hold Kelsey. I went home with Aunt Kathy. I went to my friend Ericas
house. When I woke up there were people around. Daddy carried me home. The
people at the hospital were very nice. They gave me a Koala bear.
I stayed home from school. People came over to visit. Daddy called the coroners
office to find out when Kelsey would be sent to the funeral home. Kelsey broke her
head, some ribs, and maybe her neck. It broke our hearts. I remember that!
When Kelsey was being born, I helped with everything. It was the same with this. We
all went to Lazarus to pick out a dress for Kelsey to be buried in. It had sparklies and
a bow. She wouldve loved it. I got one too. Shelby and I put most of Kelseys shoes
in a bag. We went to see Mr. Zalewski (Walt) at the funeral home. We went to pick
the casket. They had all different kinds, but just one for children. We picked out the
funeral cards. We made all the arrangements for the funeral. Friday night was a
private family viewing. We went in by ourselves first. We went in and said hi and cried.
We wanted to see her. She looked like herself but like she was asleep. I touched her
arm. She was very cold. Ice cold. Then the family came in. We stood up by the casket
and people came up to see Kelsey and to support us. There were lots of hugs and
kisses. We put flowers and notes and pictures and a Barbie in her casket. I put a
picture or note in. Saturday we had a viewing for everyone. There were so many
people. We were there from two to four. Then the family went to eat. We stayed and
ate downstairs. I went with Grandma for awhile. Seven to nine was another viewing.
Sunday were viewings again. JJ brought Lauren a maroon bear. Kelsey got a white
one. Mommy and I went to Kelsey and sang You are My Sunshine and I Love You
a Bushel and a Peck. Me and my friends sold penny candy for $1. We got about
$20, and I bought mass cards for Kelsey.
Monday was the funeral. It was at 10 a.m. We went to the funeral home and said
our final goodbyes to Kelsey. We rode in a limo to the church. The priest blessed us.
Father Joe was crying. We cant remember what he said. We rode in the limo to the
cemetery. The cemetery was really big. There were a lot of people waiting in line to
come to her grave. I remember seeing her being buried. After the funeral we had a
wake. It was a party for our family and friends to show their support. I remember
getting presents and getting chips, pretzels, and Pepsi. People were talking and crying.
I wore my daddys jacket. After the wake, we went to Grandmas house. I didnt go
back to school until the end of the week. The kids were hugging me. They made cards
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for us. I didnt want to go back. My teachers knew. I didnt like that. It was my personal
business. One day we were watching a movie about whales. It made me think about
Kelsey. I was crying and my parents had to come pick me up. Its hard to get over.
About one week later, we went to pick out the headstone. They had all different
shapes and sizes. I picked out the marble piece and it was multicolored. The plaque
was Aztec blue. Gone so young form our loving hearts It was at the cemetery
about a month later.
I went to school and soon. Mom and Dad went back to work. People sent cards and
money every day. The church took up a collection for us. Looking back on everything,
my life has changed a lot without Kelsey here. Its changed me. I appreciate life more
and try to do well in school. I miss her in my life. I miss her sleeping with me. I miss
hugging her. Im sad because my mom and dad cry. If I had a friend who had a brother
or sister die, I would tell them to go see a therapist and they will help you a lot and
make you feel at home. Its hard to talk about, but it made me feel better to talk
about it. We learned a lot here. It makes you a lot better about your loss. I knew Ill
always miss Kelsey, but Ill always remember her in my heart.
The End
*NOTE: The original trauma narrative included illustrations as shown in Its OK to
Remember.
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anything because I was in shock. I didnt know what to think or feel. A detective had
come and asked my mom questions about what had happened. My grandma came
and so did Harolds mom and one of his grown-up daughters. I felt really bad for my
mom because when Harolds mom and his daughter pulled up his daughter got out of
the car and was screaming what did you do to my father?! His mom was praying
and I got out of the police car and gave her a hug. After a lot of commotion had gone
on, my mom, Grandma, and I went back to my grandmas house and tried to sleep.
Chapter 5: The After Days
Harold committing suicide wasnt all bad. My mom has gotten involved in her church a
lot more and has stopped drinking. She has also been spending more time with me. I
have changed in ways too. I dont take things for granted anymore. I appreciate things
in new ways, because you never really know how much something means to you until
its gone. I have thought a lot about the way Harold died. Sometimes it makes me
upset because how could someone do such a foolish thing? Its selfish, I think when
you commit suicide because youre not thinking about the people that love you. If
Harold wasnt drunk I dont believe he would have done that. He was drunk at the
time and when youre drunk youre not in your right mind. I dont think he killed
himself purposely to hurt my mom. I knew he loved her and would never want her to
go through that kind of pain. If he had done it on purpose then he really wasnt the
person I thought he was. I think he is 100 percent responsible for what he did
because he chose to get drunk and he chose to let himself get upset and everything.
My mom tried to help him not drink. I dont really think anyone could have stopped
him from doing what he did. My mom once tried to get him to go to therapy or
something. He said he would but I guess he didnt. If this happened to another child
I would tell them that everything happens for a reason. Dont always think about the
negative about the situation. It may help you get stronger like it has with me.
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Parents, caregivers, and important adults can help children cope with childhood
traumatic grief.
Help is available to parents and children who are experiencing childhood
traumatic grief.
Childhood traumatic grief is a condition that some children develop after the death
of a close friend or family member. Children with childhood traumatic grief experience
the cause of that death as horrifying or terrifying, whether the death was sudden
and unexpected (due to homicide, suicide, motor vehicle accident, natural disaster,
war, terrorism, or other causes) or due to natural causes (such as cancer or a heart
attack). Even if to you, as the adult, the manner of death does not seem to be
sudden, shocking, or frightening, the child may perceive the death in this way and
can be at risk of developing childhood traumatic grief.
When a child is struggling with childhood traumatic grief, the childs trauma reactions
interfere with his or her ability to go through a normal bereavement process. Because
of the interaction of traumatic and grief reactions, any thoughts, even happy ones, of
the deceased person can lead to frightening memories of how the person died. Because
these thoughts can be so upsetting, the child often may try to avoid all reminders of
the loss so as not to stir up upsetting thoughts or feelings. A younger child may be
afraid to sleep alone at night because of nightmares about a shooting that she
witnessed, while an older child may avoid playing on the school baseball team his
father used to coach because it brings up painful thoughts about how his father died
in a terrible car accident. In this way, the child can get stuck on the traumatic
aspects of the death and cannot proceed through the normal bereavement process.
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Adjust to changes in their lives and identity that result from the death
Develop new relationships or deepen existing relationships with friends and family
Invest in new relationships and life-affirming activities
Maintain a continuing, appropriate attachment to the person who died through
such activities as reminiscing, remembering, and memorialization
Make some meaning of the death that can include coming to an understanding
of why the person died
Continue through the normal developmental stages of childhood and adolescence
For children experiencing childhood traumatic grief, thinking or talking about the
person who died often leads to thoughts of the traumatic manner of death. For this
reason, these children often try to avoid thinking or talking about the person who
died and avoid facing the frightening feelings associated with these reminders. This
prevents them from completing the tasks of normal bereavement mentioned above.
What Are Some Common Signs that a Child Is Struggling with Traumatic Grief?
Not all children who experience a traumatic death will develop childhood traumatic grief.
Some children will be able to grieve the loss without complications. A small number of
grieving children may develop some reactions or symptoms that can become difficult
and perhaps interfere with their daily functioning. Signs that a child is having difficulty
coping with the death may be noticeable in the first month or two or may not be
apparent until one or more years later. Some of these signs include the following:
Intrusive memories about the death: These can be expressed by nightmares,
guilt or self blame about how the person died, or recurrent or disturbing thoughts
about the terrible way someone died.
Avoidance and numbing: These can be expressed by withdrawal, acting as if not
upset, or avoiding reminders of the person, the way he or she died, or the things
that led to the death.
Physical or emotional symptoms of increased arousal: Children may show this
by their irritability, anger, trouble sleeping, decreased concentration, drop in
grades, stomachaches, headaches, increased vigilance, and/or fears about
safety for oneself or others.
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What Additional Challenges Can Increase the Risk of Childhood Traumatic Grief?
(Secondary Adversities)
Children who must face additional difficult experiences as a result of the death or are already
facing stressful life circumstances are at risk for developing traumatic grief. For example,
after a fathers death, a child who has to move must contend with both the death of her
parent as well as changes in her social network, and a child who is witness to the murder
of a family member must deal with legal procedures and unpleasant questions from peers.
What Can Parents Do to Help Children and Teenagers?
Parents can play a very important role in helping children and adolescents affected by
childhood traumatic grief. Children may be struggling with finding ways to understand
and cope with their reactions to a traumatic loss. Here are some suggestions about
ways that parents can help support children:
Be aware of the common reactions of children to death described above.
Remember that not all children will develop childhood traumatic grief, and those
that do may demonstrate a range of symptoms depending on their developmental
level, personality, and prior history of traumatic experiences.
Provide children of all ages with opportunities to talk about their worries and
concerns. Children at different ages may need different types of support.
Younger children may need more attention, patience, understanding, and a few
extra hugs. Older children may need reassurance that it is normal to experience
a range of reactions and that there are adults in their lives to help them through
difficult times. Some children, especially older children, may not want to talk
about their experiences and feelings or may shut adults out.
Understand that anger or regressive behavior may be a part of a child or
adolescents reaction to a traumatic loss.
Recognize that children of all ages carefully observe how the adults in their lives
are reacting and will often take their cues from the adults around them. Children
will find comfort by observing how adults manage difficult reactions and model
effective ways of coping.
Be prepared to revisit the loss with children as they become older and acquire
new information, develop new questions, and have new experiences.
Seek support from friends and family to help manage your own grief.
Reach out for professional help if youre concerned that a childs reactions are
affecting his or her daily life.
Additional help is available through the National Child Traumatic Stress Network at
(310) 235-2633 and (919) 682-1552 or at NCTSN.org.
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Grieving. Washington, DC: Taylor & Francis, 1741.
Pfeffer, C. R., Jiang, H., Kakuma, T., Hwang, J., Metsch, M. (2002) Group intervention
for children bereaved by the suicide of a relative. Journal of the American Academy of
Child and Adolescent Psychiatry, 41 (5), 505513.
Prigerson, H. G. & Jacobs, S. C. (2001). Diagnostic criteria for traumatic grief. In Stroebe,
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Pynoos, R. (1992) Grief and trauma in children and adolescents. Bereavement Care,
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Pynoos, R., Nader, K. (1990) Childrens exposure to violence and traumatic death.
Psychiatric Annals, 20 (6), 334344.
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(Eds.), Psychological Trauma: A Developmental Approach. Arlington, VA: American
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Raphael, B., Martinek, N. (1997) Assessing traumatic bereavement and posttraumatic
stress disorder. In Wilson, J. P., Keane, T. M. (Eds.), Assessing Psychological Trauma
and PTSD, New York: Guilford Press, 373395
Saltzman, W. R., Layne, C. M., Steinberg, A. M., Pynoos, R. S. (in press). Trauma/
grief-focused group psychotherapy with adolescents. In Schein, L. A., Spitz, H. I.,
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Manuals
Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement in
children: Treatment manual, available by contacting the National Resource Center for
Child Traumatic Stress at (919) 682-1552 or nationalresourcecenter@duke.edu.
Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement in
children: Group treatment manual, available by contacting the National Resource Center
for Child Traumatic Stress at (919) 682-1552 or nationalresourcecenter@duke.edu.
Lieberman, A. F., Compton, N. C., Van Horn, P. & Ghosh Ippen, C. (2003) Losing
a parent to death in the early years: Guidelines for the treatment of traumatic
bereavement in infancy and early childhood. Washington, DC: Zero to Three Press.
Saltzman, W. R., Layne, C. M., Pynoos, R. S. (2003) Trauma/grief-focused intervention
for adolescents, available by contacting wsaltzman@sbcglobal.net.
Training
Contact the National Child Traumatic Stress Network at (310) 235-2633 or
(919) 682-1552 or www.NCTSN.org
Websites
National Center for PTSD, Managing Grief after Disaster.
www.ncptsd.org/facts/disasters/fs_grief_disaster.html
National Child Traumatic Stress Network: NCTSN.org
The Courage to Remember: Childhood Traumatic Grief Curriculum Guide
National Child Traumatic Stress Network
NCTSN.org
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